Healthcare Provider Details

I. General information

NPI: 1386246221
Provider Name (Legal Business Name): LAGUNA HEALTHCARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 BASSWOOD RD
PARAJE NM
87007
US

IV. Provider business mailing address

PO BOX 549
PARAJE NM
87007-0549
US

V. Phone/Fax

Practice location:
  • Phone: 505-431-0750
  • Fax: 505-431-0749
Mailing address:
  • Phone: 505-431-0711
  • Fax: 505-431-0749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TISCHA BECKER
Title or Position: PHARMACY DIRECTOR
Credential: PHARMD
Phone: 505-431-0750